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Despite the proven benefit of stent retrievers, challenges to rapid revascularization of large vessel occlusions (LVO) persist. Current stent retrievers have limited effectiveness for removing organized thrombi. The NeVa device is a novel stent retriever designed with openings in the basket cell structure (“drop zones”) intended to capture organized thrombi within the central scaffold during retrieval. Prospective, multicenter, open label, single arm, FDA-regulated IDE study to evaluate the performance of the NeVa device for recanalizing occluded intracranial vessels including ICA, M1/M2 MCA, and vertebrobasilar arteries, within 8 hours of onset. Primary endpoint was rate of eTICI 2b-3 within 3 NeVa passes, tested for non-inferiority against a performance goal of 72% with a margin of -10%. Additional efficacy endpoints included first pass effect to eTICI 2b-3 (FPE) and 90-day mRS 0-2. Primary safety endpoint was 90-day mortality. (ClinicalTrials.gov NCT04514562) (Site-adjudicated revascularization results are reported here. Final core lab results will be presented at the conference.) From April 1, 2021 to April 28, 2022, 139 subjects were enrolled at 25 centers in the US and Europe. Mean age was 67 ± 13 years; 47% were female. Median NIHSS score was 16 (IQR: 12-20). Occlusions were 14 (10%) ICA, 85 (61%) M1, 38 (27%) M2, 1 (1%) Basilar and 1 (1%) PCA. Mean time to first pass was 19 ± 12 minutes. eTICI 2b-3 within 3 NeVa passes occurred in 87.8% (122/139; CI 81.1%,92.7%; non-inferiority p

Malignant cerebral edema (MCE) and intracranial hemorrhage (ICH) are associated with poor neurological outcomes despite revascularization after mechanical thrombectomy (MT). The factors associated with the development of MCE and ICH after MT are not well understood.To determine periprocedural factors associated with MCE, ICH, and poor functional outcome.We retrospectively analyzed anterior cerebral circulation large vessel occlusion cases that underwent MT from 2012 to 2019 at a single Comprehensive Stroke Center. Multivariate logistic regression analyses were performed to determine significant predictors of MCE, ICH, and poor functional outcome (modified Rankin Scale, 3-6) at 90 d.Four hundred patients were included. Significant independent predictors of MCE after MT included initial stress glucose ratio (iSGR) (odds ratio [OR], 14.26; 95% CI, 3.82-53.26; P.001), National Institutes of Health Stroke Scale (NIHSS) (OR, 1.10; 95% CI, 1.03-1.18; P = .008), internal carotid artery compared with M1 or M2 occlusion, and absence of successful revascularization (OR, 0.16; 95% CI, 0.06-0.44; P.001). Significant independent predictors of poor functional outcome included MCE (OR, 7.47; 95% CI, 2.20-25.37; P = .001), iSGR (OR, 5.15; 95% CI, 1.82-14.53; P = .002), ICH (OR, 4.77; 95% CI, 1.20-18.69; P = .024), NIHSS (OR, 1.10; 95% CI, 1.05-1.16; P.001), age (OR, 1.04; 95% CI, 1.03-1.07; P.001), and thrombolysis in cerebral infarction 2C/3 recanalization (OR, 0.12; 95% CI, 0.05-0.29; P.001).Elevated iSGR significantly increases the risk of MCE and ICH and is an independent predictor of poor functional outcome. Thrombolysis in cerebral infarction 2C/3 revascularization is associated with reduced risk of MCE, ICH, and poor functional outcome. Whether stress hyperglycemia represents a modifiable risk factor is uncertain, and further investigation is warranted.

Quasar Q0059–2735, one of the first known iron low-ionization broad-absorption-line quasars (FeLoBAL), has a plethora of outflow absorption features at different velocities. Given multiple outflow systems, their troughs from high-ionization transitions form very wide BAL features, e.g. C iv troughs extend from ∼−1000 to −25 000 km s−1. The troughs from low-ionization transitions show more than 1000 narrow absorption lines (NALs) with velocities from −1000 to −3000 km s−1. These include troughs from iron-peak elements, e.g. Fe ii, Fe iii, Cr ii, Mn ii, Ni ii, and Co ii, which are rarely detected in quasar outflows. Most of these troughs are non-black saturated. We constrain the physical conditions of the NALs by fitting the observed Fe ii and Fe iii absorption troughs. We find that the Fe ii absorption arises from a region with an electron temperature (Te) of ∼8000 K and an electron number density (ne) of ∼108 cm−3. The same model also fits well the troughs from other iron-peak elements. In contrast to the Fe ii lines, Fe iii lines are formed in a hotter region, i.e. Te ∼20 000 K. To fit the Fe ii and Fe iii lines simultaneously in a single photoionized cloud, they require a supersolar iron abundance and/or other heating mechanisms for the Fe iii region. The distance (R) of the outflows to the central quasar is determined to be ∼40 pc. The high-resolution data afforded by the Very Large Telescope (VLT)/UVES observations from 2006 and 2018, along with the narrow lines, allow us to constrain the smallest outflow deceleration in any known quasars.

BackgroundElevated International Normalized Ratio (INR) is a marker of coagulopathy, but its impact on outcomes following mechanical thrombectomy (MT) in patients with stroke is unclear. This study investigates the impact of mild INR elevations on clinical outcomes following MT.MethodsIn this retrospective cohort study, consecutive patients with stroke treated with MT were identified from 2015 to 2020 at a Comprehensive Stroke Center. Demographic information, past medical history, INR, National Institutes of Health Stroke Scale score, use of tissue plasminogen activator, and last known normal to arteriotomy time were recorded. Outcome measures included modified Thrombolysis in Cerebral Infarction (mTICI) score, modified Rankin Scale (mRS) score at 90 days, and intracerebral hemorrhage (ICH). Patients were divided into two groups: normal INR (0.8–1.1) and mildly elevated INR (1.2–1.7).ResultsA total of 489 patients were included for analysis, of which 349 had normal INR and 140 had mildly elevated INR. After multivariable adjustments, mildly elevated INR was associated with lower odds of excellent outcomes (mRS 0–1, OR 0.24, p=0.009), lower odds of functional independence (mRS 0–2, OR 0.38, p=0.038), and higher odds of 90-day mortality (OR 3.45, p=0.018). Elevated INR was not associated with a higher likelihood of ICH, and there were no differences in rates of HI1, HI2, PH1, or PH2 hemorrhagic transformations; however, elevated INR was associated with significantly higher odds of 90-day mortality in patients with ICH (OR 6.22, p=0.024). This effect size was larger than in patients without ICH (OR 3.38, pConclusionIn patients with stroke treated with MT, mildly elevated INR is associated with worse clinical outcomes after recanalization and may worsen the mortality risk of hemorrhagic transformations.

BackgroundCatheter retention and difficulty in retrieval have been observed during embolization of brain arteriovenous malformations (bAVMs) with the Onyx liquid embolic system (Onyx). The Apollo Onyx delivery microcatheter (Apollo) is a single lumen catheter designed for controlled delivery of Onyx into the neurovasculature, with a detachable distal tip to aid catheter retrieval. This study evaluates the safety of the Apollo for delivery of Onyx during embolization of bAVMs.MethodsThis was a prospective, non-randomized, single-arm, multicenter, post-market study of patients with a bAVM who underwent Onyx embolization with the Apollo between May 2015 and February 2018. The primary endpoint was any catheter-related adverse event (AE) at 30 days, such as unintentional tip detachment or malfunction with clinical sequelae, or retained catheter. Procedure-related AEs (untoward medical occurrence, disease, injury, or clinical signs) and serious AEs (life threatening illness or injury, permanent physiological impairment, hospitalization, or requiring intervention) were also recorded.ResultsA total of 112 patients were enrolled (mean age 44.1±17.6 years, 56.3% men), and 201 Apollo devices were used in 142 embolization procedures. The mean Spetzler–Martin grade was 2.38. The primary endpoint was not observed (0/112, 0%). The catheter tip detached during 83 (58.5%) procedures, of which 2 (2.4%) were unintentional and did not result in clinical sequelae. At 30 days, procedure related AEs occurred in 26 (23.2%) patients, and procedure-related serious AEs in 12 (10.7%). At 12 months, there were 3 (2.7%) mortalities, including 2 (1.8%) neurological deaths, none of which were device-related.ConclusionThis study demonstrates the safety of Apollo for Onyx embolization of bAVMs.Clinical trial registrationCNCT02378883.

We analyze VLT/X-shooter data for 7 quasars, where we study the relationships between their broad absorption line (BAL) and emission line outflows. We find: 1) the luminosity of the [OIII] $\lambda$5007 emission profile decreases with increasing electron number density (n$_e$) derived from the BAL outflow in the same quasar, 2) the measured velocity widths from the [OIII] emission features and CIV absorption troughs in the same object are similar, and 3) the mean radial velocity derived from the BAL outflow is moderately larger than the one from the [OIII] emission outflow. These findings can be explained by the physical interpretation that the [OIII] and BAL outflow are different manifestations of the same wind. When we have outflows with smaller distances to the central source, their n$_e$ is higher. Therefore, the [OIII] emission is collisionally de-excited and the [OIII] luminosity is then suppressed. Comparisons to previous studies show that the objects in our sample exhibit broad [OIII] emission features similar to the ones in extremely red quasars (ERQs). This might imply that BAL quasars and ERQs have the same geometry of outflows or are at a similar evolutionary stage. We found that the physical parameters derived from the BAL outflows can explain the amount of observed [OIII] luminosity, which strengthens our claim of both BAL and [OIII] outflows are from the same wind. These estimates can be tested with upcoming James Webb Space Telescope observations., Comment: 16 pages, 9 figures

Purpose The ULTRA Registry is an multicenter, national, prospective study designed to assess aneurysm occlusion rates and safety profile of the Target® Ultrasoft and Nano coils (Stryker Neurovascular, Fremont, CA, USA) in the treatment of small intracranial aneurysms. Methods The ULTRA Registry is a prospective database of patients with small ( Results 100 patients (75% female; mean age 57.1 [SD 11.7]; 48 ruptured) were treated from December 2013 to January 2019. Stent and balloon assistance was used in 21 and 19 cases, respectively. No flow diverting stents were used. Mean aneurysm size was 3.5 x 3.0 x 2.8 mm (SD 0.9 x 1 x 0.9 mm, respectively), and mean neck size was 2 mm (SD 0.7 mm). Mean number of coils placed in each aneurysm was 2.9 (SD 1.6), and mean packing density was 34.3% (SD 16.6). First follow up imaging was MRA in 50 cases and DSA in 28 cases (mean 5.7 months [SD 2.4]), and second follow up imaging was DSA in 60 cases and MRA in 2 cases (mean 14.7 months [SD 5.6]). Residual aneurysm on the Raymond Roy Scale per investigator and core lab reporting was present at baseline post-coiling, 1st imaging follow up, and 2nd imaging follow up in 3% and 8%, 9% and 12.8%, and 11.3% and 12.9%, respectively . Aneurysm recurrence by investigator report and core lab report was 12.8% and 14.3%, respectively, on first follow up and 17.7% and 21%, respectively, on second follow up. Aneurysms requiring retreatment by investigator report and core lab report were 10.3% and 10.4%, respectively, on first follow up and 9.7% and 11.3%, respectively, on second follow up. Of 9 retreated aneurysms, 8 presented as a rupture. Including both retreated aneurysms as well as those deemed as requiring retreatment, retreatment and/or need for retreatment at final imaging follow up was 18.8% per investigator report and 20.3% per core lab report. There were worse occlusion grades, higher rates of recurrence, greater need for retreatment, and more serious adverse events in ruptured vs unruptured aneurysms at 1st and 2nd follow up. There were 0 coil related complications, 0 intraoperative aneurysm ruptures, and 0 known post-operative aneurysm ruptures. There were 7 procedural related adverse events: ischemic stroke (n=3), intracranial hemorrhage from wire perforation of the anterior cerebral artery distant to and not involved by aneurysm (n=1), cellulitis (n=1), groin hematoma (n=1), lip numbness (n=1). Conclusions The ULTRA Registry demonstrates excellent safety and efficacy profiles of Target® Ultrasoft and Nano coils in the treatment of ruptured and unruptued small intracranial aneurysms with no coil related complications in the study. Disclosures G. Jindal: 1; C; Microvention, Stryker Neurovascular. R. Almardawi: None. D. Gandhi: 1; C; Microvention, InsightTech. T. Miller: 1; C; Vesalio, Microvention. S. Satti: 2; C; Cerenovus, Balt, Cerenovus, Medtronic, Stryker, Terumo, Penumbra, Q’Apel. F. Hui: None.

BackgroundThe first pass effect has been recently reported as a predictor of good clinical outcome after stroke thrombectomy. We evaluate the first pass effect on outcome and the influence of revascularization in these and other patients.MethodsWe performed a retrospective analysis of a prospectively maintained database on anterior cerebral circulation stroke thrombectomy cases from April 2012 to April 2018. Data compiled included patient demographics, presenting National Institutes of Health Stroke Scale score, vessel occlusion site, thrombectomy procedural details, and 90 day modified Rankin Scale scores.Results205 patients were included. The numbers of patients who underwent one, two, three, four, five, and six passes were 69, 70, 55, 9, 1, and 1, respectively. Successful revascularization was achieved in 87%, 83%, and 64% of patients in the one, two, and 3 or more passes groups, respectively (p=0.002). Good functional outcome was inversely correlated with number of passes when comparing the one, two, and three or more passes groups (54%, 43%, 29%; P=0.014). In patients with full revascularization, there was no significant difference in good functional outcomes between the one, two, and three or more passes groups (64%, 65%, 50%; P=0.432). Number of passes was not an independent negative predictor of good clinical outcome (OR 1.66, 95% CI 0.82 to 3.39; P=0.165).ConclusionsFirst pass thrombectomy patients have better functional outcomes compared with beyond-first pass patients. This effect is related at least in part to a higher rate of revascularization in one pass patients. Revascularization beyond the first pass should continue to be the goal of stroke thrombectomy.

Both stent-assisted coiling (SAC) and flow diversion with the Pipeline Embolization device (PED; Medtronic Inc) have been shown to be safe and clinically effective for treatment of small (10 mm) unruptured aneurysms. However, the economic impact of these different techniques has not been established.To analyze the cost-effectiveness between stent-assisted coiling and flow diversion using PED, including procedural costs, long-term outcomes, and aneurysm recurrence.A decision-analytical study was performed with Markov modeling methods to simulate patients undergoing SAC or PED for treatment for unruptured aneurysms of sizes 5 and 7 mm. Input probabilities were derived from prior literature, and 1-way, 2-way, and probabilistic sensitivity analyses (PSA) were performed.In base case calculation and PSA, PED was the dominant strategy for both the size groups, with and without consideration of indirect costs. One-way sensitivity analyses show that the conclusion remained robust when varying the retreatment rate of SAC from 0% to 50%, and only changes when the retreatment rate of PED 49%. PED remained the more cost-effective strategy when the morbidity and mortality of PED increased by 55% and when those of SAC decreased by 37%. SAC only became cost-effective when the total cost of PED is $73000 more expensive than the total cost of SAC.With increasing use of PED for treatment of small unruptured anterior circulation aneurysms, our study indicates that PED is cost-effective relative to stent coiling irrespective of aneurysm size. This is due to lower aneurysm recurrence rate, as well as better health outcomes.

Background The Pipeline Embolization Device (PED) has been increasingly used for the treatment of posterior circulation aneurysms. The purpose of the present study was to examine the clinical and angiographic outcomes of patients with vertebrobasilar aneurysms treated with the PED. Methods We performed a retrospective review of vertebrobasilar aneurysms treated with the PED at 4 high-volume neurovascular centers. Patient, aneurysm, and procedural data were collected, including perioperative and delayed complications. Aneurysm occlusion on follow-up imaging studies was defined as complete (100%), near-complete (>90%), or incomplete ( Results The cohort included 35 patients with 37 vertebrobasilar aneurysms who underwent 36 treatment sessions. Of the 35 patients, 10 were men (29%), and the mean patient age was 54.1 years (range, 32–75). Eight patients (23%) underwent urgent treatment because of a ruptured aneurysm (n = 6), brainstem perforator stroke (n = 1), or post-traumatic pseudoaneurysm (n = 1). Of the 37 aneurysms, 22 arose from the vertebral artery (59%) and 15 from the basilar artery (41%). Also, 19 were saccular aneurysms (51%), with a mean size of 7.7 mm (range, 1.7–38.0); 17 were fusiform aneurysms (46%), with a mean size of 11.0 mm (range, 4.3–34); and 1 was a 2.9-mm blister aneurysm. The overall procedural complication rate was 14% (5 of 36), including 3 neurologically symptomatic complications. At a mean follow-up period of 14 months (range, 3–59), 24 of 34 aneurysms (71%) were completely occluded and 29 of 34 (85%) were completely or near-completely occluded. Conclusion Our results show that Pipeline embolization of vertebrobasilar aneurysms is associated with acceptable occlusion and complication rates.

BackgroundHigh levels of platelet inhibition have been associated with hemorrhagic complications following Pipeline embolization of intracranial aneurysms. We therefore titrate clopidogrel dosing to maintain a moderate level of platelet inhibition using the VerifyNow P2Y12 assay. However, many patients demonstrate dramatic increases in platelet inhibition following treatment despite being on a consistent antiplatelet regimen. We therefore elected to explore the incidence of this phenomenon and possible predisposing factors.MethodsAll successful Pipeline aneurysm treatments performed at our institution from 2011 to 2019 with moderate procedure-day platelet inhibition levels as indicated by a VerifyNow PRU of 60–235 were included. Patients who received glycoprotein IIb/IIIa inhibitors and those treated for ruptured/symptomatic lesions were excluded. The incidence of excessive platelet inhibition defined by a PRUResultsSome 190 treatments were performed in 178 qualifying patients. A post-procedure PRU ConclusionElevations in platelet inhibition were frequently observed following flow diversion with Pipeline.

Intracranial aneurysms are common in the adult population and carry a risk of rupture leading to catastrophic subarachnoid hemorrhage. Treatment of aneurysms has evolved significantly, with the introduction of new techniques and devices for minimally invasive and endovascular approaches. Follow-up imaging after aneurysm treatment is standard of care to monitor for recurrence or other complications, and the preferred imaging modality and schedule for follow-up are areas of active research. The modality and follow-up schedule should be tailored to treatment technique, aneurysm characteristics, and patient factors.

Introduction: It remains unclear whether use of intravenous thrombolysis (IVT) with intravenous tissue plasminogen activator (tPA) provides additional benefit to patients with emergent large vessel occlusion (ELVO) stroke undergoing mechanical thrombectomy (MT). We sought to determine the impact of IVT on procedure time, number of passes, and successful reperfusion (SR) during MT. Method: We retrospectively analyzed all patients who underwent anterior circulation mechanical thrombectomy for treatment of ELVO stroke at our institution from April 2012 to November 2019. Univariate and multivariate logistic regression analyzes were used to determine independent predictors of poor functional outcome at 90 days,and independent predictors of >2 thrombectomy passes in patients with successful revascularization (SR: TICI 2B, 2C and 3). Results: A total of 400 patients were eligible for analysis. 189 patients received IVT before thrombectomy. Last known well time-to-endovascular therapy was shorter in the IVT group (290.0 min vs 452.75 min; P=2 passes relative to M1 occlusion in patients with successful revascularization. Multivariate logistic regression revealed that age (OR 1.05, 95% CI 1.03-1.07; p Conclusion: IVT pretreatment did not increase rates of SR and did not shorten MT procedure time nor number of passes needed to achieve SR during MT in our patient population. Randomized controlled trials are required for further evaluation of the impact of IVT on reperfusion status during MT.

Determining the distance of quasar absorption outflows from the central source (R) and their kinetic luminosity are crucial for understanding their contribution to active galactic nucleus (AGN) feedback. Here we summarize the results for a sample of nine luminous quasars that were observed with the Hubble Space Telescope. We find that the outflows in more than half of the objects are powerful enough to be the main agents for AGN feedback, and that most outflows are found at R>100 pc. The sample is representative of the quasar absorption outflow population as a whole and is unbiased towards specific ranges of R and kinetic luminosity. Therefore, the analysis results can be extended to the majority of such objects, including broad absorption line quasars. We find that these results are consistent with those of another sample (seven quasars) that is also unbiased towards specific ranges of R and kinetic luminosity. Assuming that all quasars have absorption outflows, we conclude that most luminous quasars produce outflows that can contribute significantly to AGN feedback. We also discuss the criterion for whether an outflow is energetic enough to cause AGN feedback effects., 10 pages, 4 figures, accepted for publication in MNRAS

BackgroundThere is a paucity of data regarding mechanical thrombectomy (MT) in distal arterial occlusions (DAO). We aim to evaluate the safety and efficacy of MT in patients with DAO and compare their outcomes with proximal arterial occlusion (PAO) strokes.MethodsThe Trevo Registry was a prospective open-label MT registry including 2008 patients from 76 sites across 12 countries. Patients were categorized into: PAO: intracranial ICA, and MCA–M1; and DAO: MCA–M2, MCA–M3, ACA, and PCA. Baseline and outcome variables were compared across the PAO vs DAO patients with pre-morbid mRS 0–2.ResultsAmong 407 DAOs including 350 (86.0%) M2, 25 (6.1%) M3, 10 (2.5%) ACA, and 22 (5.4%) PCA occlusions, there were 376 DAO with pre-morbid mRS 0–2 which were compared with 1268 PAO patients. The median baseline NIHSS score was lower in DAO (13 [8–18] vs 16 [12–20], PConclusionEndovascular therapy in DAO appears to result in a comparable safety and technical success profile as in PAO. The potential benefits of DAO thrombectomy should be investigated in future randomized trials.

Introduction Anemia has been associated with worse clinical outcomes and increased mortality following acute ischemic stroke, however, the study of anemia in acute ischemic stroke patients treated with mechanical thrombectomy has been limited. Methods We performed a retrospective study of 346 anterior circulation stroke patients treated with mechanical thrombectomy to investigate the impact of peri-procedure anemia (Hgb Results One hundred patients (29%) met the criteria for peri-procedure anemia after admission for thrombectomy. Females comprised 73% of patients (n=73) with peri-procedure anemia compared to 39% (n=97) of patients without anemia (p Conclusion Female sex and ≥3 thrombectomy passes were independently associated with peri-procedure anemia. Peri-procedure anemia was associated with worse clinical outcomes at 3-month follow-up. The interventional neuroradiologist should consider the potential adverse effects of peri-procedure anemia and minimize overall procedural blood loss when able, mainly in women that inherently have lower hemoglobin levels than men. Future studies are required to better understand the causal relationship between procedural blood loss and clinical outcomes following thrombectomy. Disclosures H. Carvalho: None. A. Wessell: None. G. Cannarsa: None. T. Miller: None. D. Gandhi: None. G. Jindal: None.

Background The development of malignant cerebral edema (MCE) after large-vessel occlusion mechanical thrombectomy (MT) with the ensuing requirement for decompressive craniectomy is a dreaded outcome of stroke. We analyzed factors associated with the development of malignant cerebral edema following mechanical thrombectomy. Methods We performed a retrospective analysis of anterior cerebral circulation large vessel occlusion cases that underwent MT from April 2012 to November 2019 at single comprehensive stroke center. Data included patient demographics, presenting NIHSS score, vessel occlusion site, onset-to-revascularization timing, presenting blood glucose, 90 day modified Rankin Scale (mRS), post-procedural intracerebral hemorrhage (PH1 or PH2), and post-procedural development of MCE (midline shift greater than 5 mm associated with neurological deterioration after greater than 50% infarction of the MCA territory). Multi-variate logistic regression analyses were performed to determine significant predictors of malignant „cerebral edema and poor functional outcome (mRS 3–6) at 90 days. Results 400 patients were included in the analysis. 42 (10.5%) patients developed MCE following mechanical thrombectomy with 26 (6.5%) patients undergoing decompressive craniectomy. Significant independent predictors of MCE following MT included: NIHSS (OR 1.10, 95% CI: 1.03–1.18; p=0.008), tPA administration (OR 2.38 95% CI: 1.04–5.46; p=0.041), 4 or more thrombectomy passes (OR 5.25, 95% CI: 1.53–17.94; p=0.008), and initial stress glucose ratio (OR 14.92 95% CI: 3.95–56.43; p Conclusion Our data demonstrate an association of malignant cerebral edema with ICA occlusion, higher presenting NIHSS scores, tPA administration, 4 or more thrombectomy passes, and a high initial stress glucose ratio. Malignant cerebral edema is associated with poor functional outcome at 90 days. Further investigation of causes of malignant cerebral edema after MT are warranted. Disclosures G. Cannarsa: None. A. Wessell: None. T. Chryssikos: None. K. Kim: None. J. Stokum: None. H. Carvalho: None. T. Miller: None. D. Gandhi: None. G. Jindal: None.

BACKGROUND AND PURPOSE: Previous studies in acute ischemic stroke have demonstrated the importance of minimizing delays to endovascular treatment and keeping thrombectomy procedural times at 60 minutes) and time from stroke onset to endovascular therapy (≤6 or >6 hours). Clinical characteristics of patients with postprocedural intracranial hemorrhage were also assessed. Logistic regression was used to determine independent predictors of poor outcome at 90 days (mRS ≥3). RESULTS: Greater age (OR, 1.03; 95% CI, 1.01–1.06; P = .016), higher admission NIHSS score (OR, 1.10; 95% CI, 1.04–1.16; P = .001), history of diabetes mellitus (OR, 1.96; 95% CI, 1.05–3.65; P = .034), and postprocedural intracranial hemorrhage were independently associated with greater odds of poor outcome. Modified TICI scale scores of 2c (OR, 0.11; 95% CI, 0.04–0.28; P 6 hours was independently associated with increased odds of poor outcome (OR, 2.20; 95% CI, 1.11–4.36; P = .024) in the final multivariate model (area under the curve = 0.820). Procedural time was not independently associated with clinical outcome in the final multivariate model (P > .05). CONCLUSIONS: Thrombectomy procedural times beyond 60 minutes are associated with lower revascularization rates and worse 90-day outcomes. Procedural time itself was not an independent predictor of outcome. While stroke thrombectomy procedures should be performed rapidly, our study emphasizes the significance of achieving revascularization despite the requisite procedural time. However, the potential for revascularization must be weighed against the risks associated with multiple thrombectomy attempts.

We present an analysis of the broad absorption line (BAL) velocity shift that appeared in one of the outflow systems in quasar SDSS J1042+1646. Observations were taken by the Hubble Space Telescope/Cosmic Origin Spectrograph in 2011 and 2017 in the 500 -- 1050 $\r{A}$ rest frame. The outflow's velocity centroid shifted by $\sim$ --1550 km s$^{-1}$ from --19,500 km s$^{-1}$ to --21,050 km s$^{-1}$ over a rest-frame time of 3.2 yr. The velocity shift signatures are most apparent in the absorption features from the Ne VIII $\lambda\lambda$ 770.41, 780.32 doublet and are supported by the absorption troughs from OV $\lambda$ 629.73 and the Mg X $\lambda\lambda$ 609.79, 624.94 doublet. This is the first time where a quasar outflow velocity shift is observed in troughs from more than one ion and in distinct troughs from a doublet transition (Ne VIII). We attribute the velocity shift to an acceleration of an existing outflow as we are able to exclude photoionization changes and motion of material into and out of the line of sight as alternate explanations. This leads to an average acceleration of 480 km s$^{-1}$ yr$^{-1}$ (1.52 cm s$^{-2}$) in the quasar rest frame. Both the acceleration and the absolute velocity shift are the largest reported for a quasar outflow to date. Based on the absorption troughs of the O V* multiplet, we derive a range for the distance of the outflow ($R$) from the central source, 0.05 pc $, Comment: 10 pages, 6 figures, published in ApJS

We present the analysis of two outflows (S1 at --5500 km s$^{-1}$ and S2 at --9700 km s$^{-1}$) seen in recent HST/COS observations of quasar SDSS J0755+2306 (z = 0.854). The outflows are detected as absorption troughs from both high-ionization species, including N III, O III, and S IV, and very high-ionization species, including Ar VIII, Ne VIII, and Na IX. The derived photoionization solutions show that each outflow requires a two ionization-phase solution. For S1, troughs from S IV* and S IV allow us to derive an electron number density, $n_{e}$ = 1.8$\times$10$^4$ cm$^{-3}$, and its distance from the central source of $R$ = 270 pc. For S2, troughs from O III* and O III yield $n_{e}$ = 1.2$\times$10$^3$ cm$^{-3}$ and $R$ = 1600 pc. The kinetic luminosity of S2 is $>$ 12% of the Eddington luminosity for the quasar and therefore can provide strong AGN feedback effects. Comparison of absorption troughs from O III and O VI in both outflow systems supports the idea that for a given element, higher ionization ions have larger covering fractions than lower ionization ones., Comment: 10 pages, 6 figures, published in ApJS

From Hubble Space Telescope/Cosmic Origins Spectrograph spectra of five quasars, 16 outflows are detected. For 11 outflows, we are able to constrain their distances to the central source (R) and their energetics. In instances of multiple electron number density determinations (used in the calculation of R) for the same outflow, the values are consistent within errors. For the 11 outflows, eight have measurements for R (between 10 and 1000 pc), one has a lower limit, another has an upper limit, and the last has a range in R. There are two outflows that have enough kinetic luminosity to be major contributors to active galactic nucleus feedback. The outflowing mass is found primarily in a very high-ionization phase, which is probed using troughs from, e.g., Ne VIII, Na IX, Mg X, and Si XII. Such ions connect the physical conditions of these ultraviolet outflows to the X-ray warm absorber outflows seen in nearby Seyfert galaxies. The ion Cl VII and several new transitions from Ne V have been detected for the first time., Comment: 29 pages, 3 figures, 4 tables, Accepted for publication in ApJS

Purpose The Apollo Onyx Delivery Microcatheter (Ev3, Irvine, CA) is a detachable-tip microcatheter that was developed to reduce the risk of microcatheter entrapment during ethylene-vinyl alcohol copolymer (Onyx) embolizations. We report our experience with the microcatheter in a variety of neurointerventional procedures. Methods We retrospectively reviewed all Onyx embolizations performed in the head, neck, and spine using the Apollo Onyx Delivery Microcatheter from its introduction at our institution in July 2014 to August 2016. Information regarding patient diagnoses, procedural details, as well as clinical outcomes were obtained from the electronic medical record, procedure reports, and relevant angiographic imaging. Results A total of 58 arterial pedicle Onyx embolizations were performed in 37 patients. There were no cases of microcatheter entrapment, early/inadvertent tip detachment, or vessel injury upon removal of the device. There were two instances (3.5%) of leakage of Onyx from the microcatheter detachment site during embolization, which did not result in adverse sequelae. Clinical outcomes were excellent, with nearly all embolizations achieving the intended goal. In multivariate analysis, length of Onyx reflux along the microcatheter tip and utilization of a higher viscosity agent, Onyx 34, were significantly associated with tip detachment. Conclusion The use of the Apollo Microcatheter is both safe and effective during neurointerventional embolizations using Onyx. Leakage of liquid embolic agent from the detachment site is an infrequent technical complication that may be encountered with the device.

A 60-year-old woman, a nonsmoker, with medical history of hypertension and chronic back pain, presented with sudden-onset left-sided weakness and facial droop to an outside hospital with symptoms of approximately 1 hour duration. Her NIH Stroke Scale (NIHSS) score, a validated tool to quantitatively measure stroke severity,1 was 17, significant for a right gaze preference, left-sided hemiparesis, and left-sided neglect. Her initial head CT demonstrated an Alberta Stroke Programme Early CT Score (ASPECTS) of 9. ASPECTS is a 10-point quantitative CT scan topography score used to measure ischemic changes on head CT.2 The patient's head CT demonstrated subtle right basal ganglia ischemic involvement and an absence of hemorrhage. IV tissue plasminogen activator (tPA) was administered and CT angiography of the head and neck was performed, demonstrating a right middle cerebral artery (MCA) (M1) occlusion. Our institution was consulted as per protocol for ischemic strokes associated with large artery occlusion and she was transferred for potential intra-arterial (IA) thrombectomy. Upon arrival, the patient was mildly lethargic but attended to the examination; she was able to follow simple commands to open/close her eyes and make a fist. The patient was dysarthric, but with time, answered questions appropriately. She had left-sided facial weakness and right gaze preference but was able to cross midline. She demonstrated left-sided neglect to visual and tactile stimuli and was slow to move her left extremities to repeated command, with decreased left-sided extremity strength rated 4/5. NIHSS upon arrival to our institution was 9.

Graphical Abstract Graphical Abstract

BackgroundThe utility of using the VerifyNow P2Y12 platelet inhibition assay in patients undergoing Pipeline embolization of intracranial aneurysms remains controversial. As we have routinely employed the assay for patients undergoing flow diversion, we elected to explore the relationship between P2Y12 hyporesponse as indicated by a P2Y12 Reaction Units (PRU) value >200 and treatment outcomes, including intraprocedural platelet aggregation and ischemic complications.MethodsAll successful intracranial aneurysm Pipeline treatments performed at our institution from November 2011 to May 2019 were included. The rate of P2Y12 hyporesponse and treatment outcomes were evaluated. Multivariable logistic regression was utilized to determine independent predictors of treatment outcomes.Results333 qualifying treatments were performed in 297 patients. Clopidogrel hyporesponse was initially noted in 24%, falling to 17% by day-of-procedure by dose titration. A glycoprotein (GP) IIb/IIIa inhibitor was administered prophylactically in 3% of cases for persistent, profound hyporesponse. 27 (8.1%) patients developed acute platelet aggregation; only 6 demonstrated day-of-procedure P2Y12 hyporesponse. Day-of-procedure hyporesponse was not associated with intraprocedural platelet aggregation or ischemic complications. Greater Pipeline embolization device (PED) diameter was associated with a reduced odds of platelet aggregation (OR 0.38, 95% CI 0.17 to 0.85; p=0.019). Antiplatelet non-compliance (OR 25.20, 95% CI 3.86 to 164.61; p=0.001) and treatment of posterior circulation aneurysms (OR 5.23, 95% CI 1.22 to 22.33; p=0.026) were the only independent predictors of ischemic complications.ConclusionsP2Y12 hyporesponse was not associated with acute platelet aggregation or ischemic complications in our patients undergoing Pipeline embolization of intracranial aneurysms, possibly due to aggressive management of the hyporesponse using clopidogrel dose titration and/or GP IIb/IIIa inhibitor administration.

Purpose Advancements in catheter technology have allowed for greater flexibility and trackability. We report 265 consecutive, single-center neurointerventional cases using the Navien guide catheter. Materials and methods Retrospective analysis was performed of consecutive intracranial endovascular procedures utilizing the Navien catheter. Data collected included procedure type, catheters, guide catheter position, cervical access artery tortuosity grade and complications. Results The 5 French catheter was used in 130 cases. The 6 French catheter was used in 135 cases. Access was via the internal carotid artery in 204, external carotid artery in 10, and vertebral artery in 51 cases. Catheter tip position was in the petrous segment of the internal carotid artery in 36.6% (97/265), distal cervical internal carotid artery in 13.9% (37/265), cavernous internal carotid artery in 10.2% (27/265), proximal or mid cervical internal carotid artery in 5.6% (15/265), supraclinoid internal carotid artery in 0.8% (2/265), and intradural vertebral artery in 0.8% (2/265) of cases. Catheter position was not determined in 18.9% (50/265) of cases. Proximal vessel tortuosity (grade B or C) was present in 98 cases (37%), and the catheter was tracked distal to the tortuosity in 93% (91/98) of these cases. The overall success rate without catheter complication was 97% (258/265). The Navien was replaced by another catheter in 1.9% (5/265) of cases. There was one cervical artery dissection (0.4%) and one severe vasospasm (0.4%) necessitating Navien removal. Conclusions The Navien guide catheter provided distal access support for neuroendovascular interventions in nearly all cases, including cases with proximal artery tortuosity, with a low rate of catheter-related complications.

A wide range of congenital and acquired vascular entities may occur in the skull base. Although some are diagnosed incidentally and merit no treatment, others may require surgical or image-guided endovascular or percutaneous approaches for management. The complex anatomy of the skull base can make diagnosis challenging. A combination of computed tomography scans and MR imaging, and catheter angiography may be required for diagnosis and mapping. Endovascular treatment plays an important part in many of the acquired vascular lesions, such as vascular neoplasms and traumatic dissections/aneurysms. Endovascular treatment is generally considered the gold standard for the treatment of vascular shunts at the skull base.

BACKGROUND AND PURPOSE: Neurointerventional surgery may expose patients and physician operators to substantial amounts of ionizing radiation. Although strategies for reducing patient exposure have been explored in the medical literature, there has been relatively little published in regards to decreasing operator exposure. The purpose of this study was to evaluate the efficacy of shielding systems in reducing physician exposure in a modern neurointerventional practice. MATERIALS AND METHODS: Informed consent was obtained from operators for this Health Insurance Portability and Accountability Act–compliant, institutional review board–approved study. Operator radiation exposure was prospectively measured during 60 consecutive neurointerventional procedures from October to November 2013 using a 3-part lead shielding system. Exposure was then evaluated without lead shielding in a second 60-procedure block from April to May 2014. A radiation protection drape was randomly selected for use in half of the cases in each block. Two-way analysis of covariance was performed to test the effect of shielding systems on operator exposure while controlling for other covariates, including procedure dose-area product. RESULTS: Mean operator procedure dose was 20.6 μSv for the entire cohort and 17.7 μSv when using some type of shielding. Operator exposure significantly correlated with procedure dose-area product, but not with other covariates. After we adjusted for procedure dose-area product, the use of lead shielding or a radiation protection drape significantly reduced operator exposure by 45% (F = 12.54, P < .0001) and 29% (F = 7.02, P = .009), respectively. The difference in protection afforded by these systems was not statistically significant (P = .46), and their adjunctive use did not provide additional protection. CONCLUSIONS: Extensive lead shielding should be used as much as possible in neurointerventional surgery to reduce operator radiation exposure to acceptable levels. A radiation protection drape is a reasonable alternative when standard lead shielding is unavailable or impractical to use without neglecting strategies to minimize the dose.

Introduction The Sofia 6-French PLUS catheter is a recently approved aspiration catheter for use in neuro-endovascular procedures. The description of Sofia 6-French PLUS use in acute ischemic stroke is limited. Objective The purpose of this article is to describe our initial experience with the new Sofia 6-French PLUS catheter for treatment of acute ischemic stroke and to report on its safety and efficacy. Methods We performed a retrospective study of 54 thrombectomy cases treated with the Sofia 6-French PLUS catheter. Mean patient age and admission National Institutes of Health Stroke Scale score were 65.30 (1.92) and 15.98 (0.89), respectively. The most common sites of vessel occlusion included the M1 segment (50%) and internal carotid artery (31%). Thrombectomy was performed using the direct aspiration first pass technique and/or aspiration in conjunction with a stent retriever. Results Successful navigation of the Sofia 6-French PLUS catheter to the site of thromboembolus was achieved in 94% of cases. Revascularization was achieved in a total of 47 cases (87%). Mean time from groin access to revascularization was 42.79 (3.23) min. There were no catheter-related complications. Final outcome data was available for 44 patients (81%). Of these patients, 41% achieved a good outcome (modified Rankin scale score of 0–2) at 60–90 day follow-up, 41% had a poor outcome (modified Rankin 3–5) and eight patients died (18%). Conclusions We demonstrate the safe and effective use of the Sofia 6-French PLUS catheter for treatment of acute ischemic stroke. Future studies in the form of a randomized clinical trial or multicenter registry are warranted to further evaluate its comparative safety and efficacy.

OBJECTIVEMagnetic resonance–guided focused ultrasound (MRgFUS) ablation of the globus pallidus interna (GPi) is being investigated for the treatment of advanced Parkinson’s disease symptoms. However, GPi lesioning presents unique challenges due to the off-midline location of the target. Furthermore, it remains uncertain whether intraprocedural MR thermometry data can predict final lesion characteristics.METHODSThe authors first performed temperature simulations of GPi pallidotomy and compared the results with those of actual cases and the results of ventral intermediate nucleus (VIM) thalamotomy performed for essential tremor treatment. Next, thermometry data from 13 MRgFUS pallidotomy procedures performed at their institution were analyzed using 46°C, 48°C, 50°C, and 52°C temperature thresholds. The resulting thermal models were compared with resulting GPi lesions noted on postprocedure days 1 and 30. Finally, the treatment efficiency (energy per temperature rise) of pallidotomy was evaluated.RESULTSThe authors’ modeled acoustic intensity maps correctly demonstrate the elongated, ellipsoid lesions noted during GPi pallidotomy. In treated patients, the 48°C temperature threshold maps most accurately predicted postprocedure day 1 lesion size, while no correlation was found for day 30 lesions. The average energy/temperature rise of pallidotomy was higher (612 J/°C) than what had been noted for VIM thalamotomy and varied with the patients’ skull density ratios (SDRs).CONCLUSIONSThe authors’ acoustic simulations accurately depicted the characteristics of thermal lesions encountered following MRgFUS pallidotomy. MR thermometry data can predict postprocedure day 1 GPi lesion characteristics using a 48°C threshold model. Finally, the lower treatment efficiency of pallidotomy may make GPi lesioning challenging in patients with a low SDR.

BACKGROUND: Subarachnoid hemorrhage (SAH) is most commonly caused by a ruptured vascular lesion. A significant number of patients presenting with SAH have no identifiable cause despite extensive cerebrovascular imaging at presentation. Significant neurological morbidity or mortality can result from misdiagnosis of aneurysm. OBJECTIVE: To generate a model to assist in predicting the risk of aneurysm in this patient population. METHODS: We conducted a retrospective study of all patients aged ≥18 yr admitted to a single center from March 2008 to March 2018 with nontraumatic SAH (n = 550). Patient information was compared between those with and without aneurysm to identify potential predictors. Odds ratios obtained from a logistic regression model were converted into scores which were summed and tested for predictive ability. RESULTS: Female sex, higher modified Fisher or Hijdra score, nonperimesencephalic location, presence of intracerebral hemorrhage, World Federation of Neurosurgical Societies (WFNS) score ≥3, need for cerebrospinal fluid diversion on admission, and history of tobacco use were all entered into multivariable analysis. Greater modified Fisher, greater Hijdra score, WFNS ≥3, and hydrocephalus present on admission were significantly associated with the presence of an aneurysm. A model based on the Hijdra score and SAH location was generated and validated. CONCLUSION: We show for the first time that the Hijdra score, in addition to other factors, may assist in identifying patients at risk for aneurysm on cerebrovascular imaging. A simple scoring tool based on patient sex, SAH location, and SAH burden can assist in predicting the presence of an aneurysm in patients with nontraumatic SAH.

Background Magnetic resonance-guided focused ultrasound ablation of the thalamic ventral intermediate nucleus is a safe and effective treatment for medically refractory essential tremor. However, indirect targeting of the ventral intermediate nucleus using stereotactic coordinates from normal neuroanatomy can be inefficient. We therefore evaluated the feasibility of supplementing this method with direct targeting of the dentato-rubro-thalamic tract. Methods We retrospectively identified four patients undergoing magnetic resonance-guided focused ultrasound ablation for essential tremor in which preoperative diffusion tractography imaging of the dentato-rubro-thalamic tract was fused with T2 weighted-imaging and utilized for intra-procedural targeting. The size and location of the dentato-rubro-thalamic tract and 24-hour lesion, as well as the center of the stereotactic coordinates, was evaluated. Finally, the amount of overlap between the dentato-rubro-thalamic tract and the lesion was calculated. Results The 24-hour lesion size was homogeneous in the cohort (mean 31.3 mm2, range 30–32 mm2), while there was substantial variation in the dentato-rubro-thalamic tract area (mean 14.3 mm2, range 3–24 mm2). The center of the stereotactic coordinates and dentato-rubro-thalamic tract diverged by more than 1 mm in mediolateral and anterposterior directions in all patients, while the dentato-rubro-thalamic tract and lesion centers were in close proximity (mean mediolateral separation 1 mm, range 0.1–2.2 mm; mean anteroposterior separation 0.75 mm, range 0.4–1.2 mm). There was greater than 50% coverage of the dentato-rubro-thalamic tract by the lesion in all patients (mean 82.9%, range 66.7–100%). All patients experienced durable tremor relief. Conclusion Direct targeting of the dentato-rubro-thalamic tract using diffusion tractography imaging fused to T2 weighted-imaging may be a useful strategy for focused ultrasound treatment of essential tremor. Further investigation of the technique is warranted.

Purpose The ULTRA Registry is an ongoing multicenter, national, prospective study designed to assess aneurysm occlusion rates and safety profile of the Target® Ultra coil and the Target® Nano coil (Stryker Neurovascular, Freemont, CA, USA) in the treatment of small intracranial aneurysms. Materials and methods The ULTRA registry is a prospective database of patients with small ( Results Patients were enrolled from December 2013 to January 2019. A total of 100 patients with 100 aneurysms were included, including 49 ruptured aneurysms. The mean age was 56±11.6 years, and 75% were female. Mean aneurysm volume was 17.7±12.4 mm3 with mean maximum and minimum aneurysm diameters of 3.7±0.9 mm and 2.6±0.7 mm, respectively. Mean packing density was 33.9%±16.6%. Stent and balloon assistance was used in 21 and 19 cases, respectively. No flow diverters were used. Initial complete occlusion, minimal residual, and residual aneurysm were reported in 45, 52, and 3 cases, respectively. There were no coil related adverse events and no intraoperative aneurysm ruptures. There were 6 procedural related adverse events: 3 ischemic strokes, 1 cerebral hemorrhage from wire perforation, 1 groin hematoma, and 1 groin infection. There was one procedural related death in the patient with cerebral hemorrhage complication. First follow up using MR angiography at a mean of 5.8±2.3 months demonstrated complete occlusion, minimal residual, and residual aneurysm in 64% (42/66), 27% (18/66), and 9% (6/66) of cases. Second follow up using digital subtraction angiography at a mean of 15.8±5.4 months demonstrated complete occlusion, minimal residual and residual aneurysm in 62% (26/42), 26% (11/42), and 12% (5/42) of cases. To date, there have been 6 aneurysm retreatments (9%; 6/66). Conclusion Initial results of the ULTRA Registry demonstrate adequate efficacy and safety profiles. Disclosures G. Jindal: 1; C; Stryker Neurovascular, Microvention. 2; C; Penumbra. R. Almardawi: None. R. Gupta: 1; C; Stryker Neurovascular, Rapid Medical. 2; C; Stryker Neurovascular, Ceronovous, Rapid Medical. 6; C; CEC committee MIND trial, Penumbra. G. Colby: 2; C; Medtronic, Stryker, Microvention. C. Schirmer: 1; C; NIH/NINDS. 6; C; AANS Honoraria, Ownership- NTI. B. Pukenas: 1; C; Stryker Neurovascular. S. Satti: 2; C; Stryker Neurovascular, Penumbra, Cerenovus, Terumo. 6; C; Medtronic – Proctor. T. Miller: None. D. Gandhi: 1; C; Stryker Neurovascular.

BACKGROUND AND PURPOSE: Although covered side branches typically remain patent acutely following Pipeline Embolization Device embolization of intracranial aneurysms, the long-term fate of these vessels remains uncertain. We therefore elected to investigate factors that may influence the long-term patency of these covered side branches. MATERIALS AND METHODS: We retrospectively evaluated the long-term patency of side branches covered by the Pipeline Embolization Device at our institution during treatment of intracranial aneurysms with at least 6 months of conventional angiography follow-up. Procedural and anatomic factors that might influence the fate of covered side branches were explored. RESULTS: One hundred forty-eight Pipeline Embolization Device treatments in 137 patients met the inclusion criteria. In 217 covered side branches, 29 (13.4%) were occluded on follow-up, and 40 (18.4%) were stenotic. All stenoses and occlusions were asymptomatic. In the entire cohort and in the largest subset of ophthalmic arteries, a smaller Pipeline Embolization Device diameter was associated with branch vessel occlusion ( P = .001, P = .013). When we considered stenotic and occluded side branches together, smaller Pipeline Embolization Device size ( P = .029) and administration of intraprocedural abciximab ( P = .03) predicted side branch stenosis/occlusion, while anterior choroidal branch type ( P = .003) was a predictor of gross side branch patency. CONCLUSIONS: A smaller Pipeline Embolization Device diameter is associated with delayed side branch stenosis/occlusion following Pipeline Embolization Device treatment, likely due to the higher metal density of smaller caliber devices. Although hemodynamic factors, including the potential for collateral flow, are still paramount in determining the fate of covered side branches, the amount of metal coverage at the side branch orifice also plays an important role.

BackgroundNew device technology has changed the techniques used for revascularization of emergent large vessel occlusion in acute stroke. We report technical results using stent retrievers (SRs) for thrombectomy alone versus SRs used in conjunction with a new group of devices, intracranial aspiration catheters (IACs). Our aim is to demonstrate differences in procedural time and thrombectomy attempts between these two groups.MethodsA retrospective evaluation was performed of a prospectively maintained database of 97 patients treated at a single institution for anterior circulation stroke with SRs. Patients were divided into two groups, a combination group defined as the SR/IAC group and the SR alone group defined as the SR group.ResultsPatients in the SR/IAC group had a mean age of 66 years vs 59 years in the SR group (p=0.008). Mean presenting National Institutes of Health Stroke Scale (NIHSS) scores in the SR/IAC and control groups were 18.7 and 18.2, respectively (p=0.50). Recanalization rates (Thrombolysis In Cerebral Infarction (TICI) 2b or 3) in the SR/IAC and SR groups were 85% (58/68) and 90% (26/29), respectively (p=0.41). Mean time from groin arteriotomy to recanalization was 50±3.6 min (range 19–136) in the SR/IAC group (n=59) and 61±6.6 min (range 28–140) in the SR group (n=27) (p=0.049). The total number of thrombectomy attempts in the SR/IAC and SR groups were 1.9±0.1 (range 1–4) and 2.5±0.6 (range 1–6), respectively (p=0.009). Post-procedural subarachnoid hemorrhage was seen in 15% (10/68) and 10% (3/29) of cases in the SR/IAC and SR groups, respectively (p=0.41).ConclusionWhen using SRs for intracranial stroke thrombectomy, the concurrent use of IACs is associated with a decrease in procedural time and thrombectomy attempts compared with use of SRs alone.

Intracranial dural arteriovenous fistulae (DAVF) are pathologic arteriovenous shunts between meningeal arteries and dural venous sinuses or veins. They account for approximately 10% to 15% of all intracranial vascular malformations and are most common in middle-aged patients. DAVF are the most common vascular cause of pulsatile tinnitus. Digital subtraction angiography remains the gold standard for diagnosing these lesions. The pattern of venous drainage determines the type of DAVF and their risk for hemorrhage. Endovascular treatment has become a first-line option for their management. This article describes the natural history, clinical presentation, classification, imaging features, and management options of intracranial DAVF.

BackgroundFlow diversion with the Pipeline embolization device is a well-established method of intracranial aneurysm treatment. However, deployment of the first-generation device (Pipeline Classic) can be technically challenging. The Pipeline Flex contains the same flow-diverting stent with a modified delivery system.ObjectiveTo compare procedural outcomes between the first-generation device (Pipeline Classic) and the Pipeline Flex.MethodsThirty-eight of the first 40 consecutive patients who underwent intracranial aneurysm treatment with the Pipeline Flex and 58 of the most recent 60 consecutive patients who underwent treatment with the Pipeline Classic at our institution were evaluated. Patient demographics, aneurysm characteristics, technical procedural details, and early outcomes were analyzed.ResultsThe two groups were comparable for age, gender, and location of target aneurysms. Use of Pipeline Flex decreased procedure time by 44.2 min (p≤0.001) and fluoroscopy time by 22.0 min (p=0.001) compared with the Pipeline Classic. Similarly, radiation exposure was less in the Flex group with a mean difference of 3473.5 Gy cm2 (p=0.002), while contrast usage was decreased with a mean difference of 22.3 mL (p=0.007). These differences remained significant in multivariate regression analysis. Finally, the rate of device deployment failure was lower in the Flex group (7.1%) than in the Classic group (23.9%) (p=0.034).ConclusionsUse of Pipeline Flex significantly reduces the total procedure and fluoroscopy time, contrast usage, patient radiation exposure, and proportion of recaptured devices in comparison with the Pipeline Classic, probably owing to an enhanced delivery system that allows for more reliable and controlled deployment.

First reported 3-dimensional quantitative study of the lower periorbital area after lower blepharoplasty using the fat repositioning technique.To determine the volumetric effects lower blepharoplasty with fat repositioning provides to the tear trough and deep fat compartments of the upper cheek.A retrospective electronic medical chart review (16-month study with a minimum of 10-month postoperative evaluation) was performed on 12 initial patients recruited to a private practice; 2 patients were lost to long-term follow-up. Patients were recruited between May 2014 and November 2014. To fulfill recruitment criteria, patients must have undergone a lower blepharoplasty performed using the fat repositioning technique with a minimum of 10 months follow-up. Patients who had undergone additional procedures or had a history of filler to the tear trough or cheek area before or during the study period were excluded.Volume (mL) measurement of a defined anatomical area in postoperative patients.Overall, 10 patients (mean [range] age, 56 [37-66] years) who had undergone a lower blepharoplasty performed using the fat repositioning technique had volume gain in the areas evaluated. The mean (range) follow-up time was 12 (10-16) months. The average volume gain was 0.64 mL (left side, 0.61 mL; right side, 0.67 mL). There was no statistical difference when the 2 sides were compared (P = .49).The fat repositioning technique in lower blepharoplasty improves pseudofat herniation while simultaneously adding volume to the lower periorbital and cheek areas. The results are reproducible with long-term aesthetic improvement in the tear trough and upper cheek areas.4.

We analyze absorption troughs from two outflows within PKS J0352-0711 (S1 at $-$1950 km s$^{-1}$ and S2 at $-$3150 km s$^{-1}$) from spectra taken with Hubble Space Telescope/Cosmic Origin Spectrograph, which cover the diagnostic-rich 585-900 Angstrom rest frame wavelength range. In S2, for the first time we clearly detect absorption troughs from Ca IV, Ca V, Ca V*, Ca VII*, and Ca VIII*. The column density measurement of Ca V suggests S2 has a super-solar metallicity. Both outflows require at least two ionization phases where the column density of the very high-ionization phase is roughly 15 times larger than the corresponding high-ionization phase. These high column densities and very high-ionization potential ions are similar to X-ray warm absorbers. The two phases of S2 show a unique velocity centroid shift between associated troughs. Through Monte Carlo measurements of the O V* absorption troughs, we determine the electron number density of S2 (fully corroborated by independent measurements from the Ca V* and Ca VIII* troughs), yielding a distance of 9 pc and a kinetic luminosity of 2$\times$10$^{43}$ erg s$^{-1}$. S1 is located farther away at 500 pc from the central source with a kinetic luminosity of 10$^{43}$ erg s$^{-1}$., Comment: 12 pages, 9 figures, 5 tables

The Hubble Space Telescope/Cosmic Origins Spectrograph (COS) has opened a new discovery space for studying quasar absorption outflows and their contribution to AGN feedback. Specifically, COS provides high-quality far-ultraviolet (FUV) spectra covering the diagnostic-rich 500-1050 Angstrom rest frame (hereafter, EUV500) of medium redshift objects. The quality and quantity of EUV500 diagnostic troughs allow us to probe the very high-ionization phase, which carries 90% or more of the outflowing material, as well as to determine the distance of most outflows from the central source ($R$). The first objective is impossible to achieve with ground-based spectra, and $R$ can be measured in only $\sim$1% of them. Here, we summarize the main results of the first dedicated survey of such outflows, including the following: 1) Measurements of the three most energetic outflows to date, which can be the main agents for AGN feedback processes in the environments of the host galaxies. 2) All the outflows have a very high-ionization component, similar to the one found in warm absorbers, which carries most of the outflow's kinetic luminosity. This finding suggests that all the high-ionization outflows observed from the ground also have a similar undetected very high-ionization component. 3) Of the 13 studied EUV500 outflows, 9 have $100, Comment: 11 pages, 4 figures, 2 tables

We present a study of the BAL outflows seen in quasar SDSS J1042+1646 (z = 0.978) in the rest-frame 500 -- 1050 $\r{A}$ (EUV500) region. The results are based on the analysis of recent Hubble Space Telescope/Cosmic Origins Spectrograph observations. Five outflow systems are identified, where in total they include $\sim$70 outflow troughs from ionic transitions. These include the first non-solar detections from transitions of O V*, Ne V*, Ar VI, Ca VI, Ca VII, and Ca VIII. The appearance of very high-ionization species (e.g., Ne VIII, Na IX, and Mg X) in all outflows necessitates at least two-ionization phases for the observed outflows. We develop an interactive Synthetic Spectral Simulation method to fit the multitude of observed troughs. Detections of density sensitive troughs (e.g., S IV* $\lambda$ 657.32 $\r{A}$ and the O V* multiplet) allow us to determine the distance of the outflows ($R$) as well as their energetics. Two of the outflows are at $R$ $\simeq$ 800 pc and one is at $R$ $\simeq$ 15 pc. One of the outflows has the highest kinetic luminosity on record ($\dot{E_{k}}$ $ = 5\times 10^{46}$ erg s$^{-1}$), which is 20% of its Eddington luminosity. Such a large ratio suggests that this outflow can provide the energy needed for active galactic nucleus feedback mechanisms., Comment: 18 pages, 12 figures, published in ApJS

We detect four very energetic outflows in the Hubble Space Telescope/Cosmic Origin Spectrograph spectra of quasar 2MASS J1051+1247 with a combined kinetic luminosity ($\dot{E_k}$) of 10$^{46}$ erg s$^{-1}$. Remarkable similarities are seen in these outflows: velocity centroids between 4900 and 5700 km s$^{-1}$, distances from the central source ($R$) of a few hundred parsecs that are all consistent within the errors, and an $\dot{E_k}$ within a factor of two for all outflows. Hence, a common origin for the outflows is probable. Most of the outflowing mass resides in a very high-ionization phase evident by troughs from Ne VIII, Na IX, Mg X, and Si XII, which connect the physical conditions of these ultraviolet outflows to the X-ray warm absorber outflows seen in nearby Seyfert galaxies. Three of the outflows have two or three independent diagnostics for the electron number density, yielding consistent values for each outflow, which increase the robustness of the $R$ determinations. Troughs from never-before-seen ionic transitions of Ar VI, O IV*, Ne VI*, and Ne V* are identified. With a combined $\dot{E_k}$ that is $7.0^{+6.5}_{-2.3}$ % of the quasar's Eddington luminosity, these outflows are prime candidates to be major agents for various active galactic nuclei feedback effects., Comment: 11 pages, 3 figures, 4 tables